AHRQ: Health IT could be disruptive while reducing rehospitalization rates, costs
The use of health IT to reduce rehospitalizations will be welcome but also disruptive, said Stephen Jencks, an independent consultant in healthcare safety during a Feb. 24 webinar on the potential use of health IT to mitigate rehospitalizations, sponsored by the Agency for Healthcare Research and Quality (AHRQ).

“We know that IT and the communities and communication it helps to create are going in the right direction, but we're uncertain how far IT will take us because we don’t have enough experience,” stated Jencks.

With 39.5 million discharges per year, the total cost associated with those discharges is $329.5 billion annually, according to Brian Jack, associate professor and vice chair in the department of medicine at Boston University School of Medicine.

Jencks said that 19.6 percent of live Medicare fee-for-service discharges are rehospitalized within 30 days. Furthermore, two-thirds of Medicare fee-for-service discharges are rehospitalized or dead within a year and half of the surgical discharges are rehospitalized or dead within a year, according to Jencks. He said that clinical trials suggest that 20 to 50 percent of rehospitalizations are preventable.

“Many rehospitalizations result from a care system’s failure in the transition from the hospital to the next source of care,” he said. Believing that reflects a lethal design flaw, Jencks said that the ultimate aim is to fix the system to prevent these care failures so the patient does not deteriorate and need rehospitalization.

“There are enormous financial implications that are on the horizon,” warned Jack. “The economy of the country could be impacted by our improvement in this area--an estimated $17 billion in the private sector and $17 billion in the public sector could perhaps be saved each year."

Jack also referenced the Obama Administration Budget Document, which plans to penalize hospitals for an over-abundance of readmissions. “Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period, saving $26 billion over 10 years,” the document reads.

The lack of follow-up and information being transmitted throughout the care system about medication changes are some of the current gaps that lead to certain rehospitalizations, according to Terry Field, associate professor at the University of Massachusetts Medical School.

Field noted a wealth of potential roles that health IT could supply to benefit the health system, including the automated scheduling of follow-up visits, automated transfer of information about medications, consistency in terms of the information provided to all healthcare professionals working with the patient, automatically identifying drug interactions, alerting nurses about need for patient education and generating support materials for the patient and family.

To introduce a possible IT solution to the rehospitalization issue, Jack introduced a ReEngineered Discharge (RED) checklist, which was created and “borrowed from engineering and patient safety movements.”

The RED contains 11 mutually reinforcing components, including medication reconciliation, a reconciled discharge plan with national guidelines, follow-up appointments, outstanding tests, post-discharge services, written discharge plan, problem-solving queries, patient education, patient understanding assessment, discharge summary and telephone reinforcement.

“We know that lots of patients are not on regimens to follow national guidelines, but why not be sure if they have indications at the time of discharge so everyone has a follow up appointment or can follow up on a reason that they were in a hospital and other chronic medical conditions,” said Jack.

In a randomized, controlled trial with 750 enrollments, Jack and colleagues found a 30 percent decrease in the number of readmissions for those 375 patients using RED compared to the 375 not using RED.

“We also saved $412 in outcome costs for each patient given RED,” said Jack.

For health IT to overcome the challenge of a registered nurse’s time, the concept of an Embodied Conversational Agent (ECA) was introduced. According to Jack, the ECA has been in development for seven years, emulates face-to-face communication and develops therapeutic alliances using empathy, gaze, posture and gestures through digital characters named “Louise” or “Elizabeth.” The ECA can also teach the RED and determine patient competency, Jack explained. Currently, the benefits of the ECA are being assessed in a clinical trial.

“They key thing is that ‘Louise’ has a lot of time,” stated Jack. Patients enjoyed that Louise is patient and not in a rush or being pulled in other directions through the day-to-day operations of a facility. “Computerized agents could be more effective than people in some context in that they rely minimally on text and using multiple modes of information can enhance recall,” added Jack.

Concluding the session, Jencks stated that to begin the health IT rehospitalization revolution, hospitals need to acknowledge the magnitude of the rehospitalization problem, the uncertainty around it and accept the need for courage to address it.